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The following Community Survey questions will take approximately 5 minutes to complete. There are 20 questions and the responses are in multiple choice form as strongly disagree, disagree, neither agree nor disagree, agree, strongly agree, and prefer not to answer. All information provided is used solely to inform our services and is kept confidential. None of your identifying information is used.

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* 1. In the past month, I have been getting quality sleep with regular bed times and getting up times.

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* 2. In the past month, I have been isolating myself from friends, family or co-workers.

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* 3. In the past month, I have had more worries or anxiety than usual.

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* 4. In the past month, I have lost interest in activities that usually held my attention.

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* 5. In the past month, I have felt more sad than happy.

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* 6. In the past month, I feel at ease with myself and my surroundings.

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* 7. In the past month, I feel that my life has been appropriately balanced between work, fun, friends, family, self-care, exercise, and other meaningful pursuits.

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* 8. In the past month, I have had trouble concentrating

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* 9. In the past month, I have been experiencing significant mood swings, crying, or thoughts of taking my own life.

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* 10. In the past month, I have been overly fatigued or tired at the end of the day.

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* 11. In the past month, my appetite or eating habits have changed.

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* 12. I believe I had these problems or issues listed above before the pandemic.

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* 13. Covid specific: In the last 12 months, I believe that COVID-19 has negatively impacted my life.

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* 14. Covid specific: In the last 12 months, I believe COVID-19 has made it more difficult to find mental health services.

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* 15. Covid specific: In the last 12 months, I believe my support system decreased because of COVID-19.

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* 16. Covid specific: In the last 12 months, I believe the media coverage on COVID-19 has impacted my current mental health in a negative way.

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* 17. Racism specific: In the last 12 months, I believe that racism impacts my current mental health in a negative way

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* 18. Racism specific: In the last 12 months, I believe that the social unrest and injustice in our communities and nation impacts my current mental health in a negative way.

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* 19. Racism specific: In the last 12 months, I believe that racial injustice impacts my current mental health in a negative way.

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* 20. Is there anything else you would like to share?

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